Cancer Management Systems: A New Value Proposition

REPORT FROM PHILADELPHIA

by Don Jewler, Director of Communications, ACCC

So, peer-directed, regularly updated oncology clinical pathways offer value to providers and payers. That was the gist of part one of ACCC’s December 8 seminar at the Fox Chase Cancer Center on cancer guidelines and pathways in the community setting.

The challenge is to integrate guidelines and pathways into oncologists’ workflow to provide ease of use and facilitate standardization of the process of collaborative care.

Enter cancer management systems, which are designed to create efficiencies, save money, and improve outcomes.

A number of companies are partnering with providers and payers to establish evidence-based oncology treatment protocols designed to offer standardized patient assessment and disease management support. Through cancer management systems, the protocols are integrated into daily workflow.

These cancer management systems “require a fully implemented oncology-specific EMR that interfaces with health systems, laboratory, outside radiology, and e-prescribing. The more sources of data that are automatically imported into the system the better,” said John D. Sprandio, MD, chief of medical oncology and hematology at Delaware County Memorial Hospital, where he also serves as director of the Delaware County Regional Cancer Center, a member of the Fox Chase Network.

According to Dr. Sprandio, cancer management systems also require:

• buy-in from providers to change their behavior
• a clinical decision-support system overlay that presents data to extract tasks away from clinicians that are not clinically relevant—like paperwork
• enhanced coordination and communication
• the ability to facilitate clinical goals and make patients the central focus of care.

In addition, they should fix accountability “on the shoulders of the physicians” and facilitate rational care decisions at the end of life.

Cancer management systems that meet these requirements can “lead to a new value proposition that you can present to payers as a higher quality service,” according to Dr. Sprandio.

Gurdeep Chhabra, MD, a medical oncologist/hematologist in Silver Spring, Md., uses a second generation cancer management system. His seven-member practice was involved in development of the first generation model, the first pathway program in the nation, through CareFirst and P4Pathways/CardinalHealth.

“Physicians were given financial incentives to participate in the CareFirst pathways first generation model. Physicians created their own pathways,” he said. The design included claims-based measurement that the physicians could view online.

Dr. Chhabra and his group wanted to move away from a traditional reimbursement model where the bulk of dollars comes from drug reimbursement margins. In the second generation model, they wanted additional incentives, end-of-life care initiatives, and a greater share of the revenue from the payer for the E&M codes they were responsible for.

Just six months in, it’s too early to determine the effect of the second generation model on quality of care. But it’s not too early to say that the new cancer management system resulted in a dramatic change in reimbursement structure and changes in practice, according to Dr. Chhabra. Analysis of E&M variation already shows increased revenues.

Ray Page, DO, PhD, president and director of research at The Center for Cancer and Blood Disorders in Fort Worth, Tex., uses a web-based cancer management system developed by D3 Oncology Solutions/Via Oncology Pathways. “With rapid growth over the last few years, we needed more consistency in practice standards to measure quality outcomes. We looked at pathways to differentiate our practice and lay the groundwork for new payment models for oncology care with United Healthcare. Our physicians have a seat on the table to develop the pathways and customize approaches.”

Dr. Page says the cancer management system allows him to identify more patients that are eligible for clinical trials and has enhanced accrual.

“If pathways sit on the shelf, they don’t help,” said Peter Ellis, MD, medical director for D3 Oncology Solutions/Via Oncology Pathways. “Docs need a delivery system that presents the pathway to make the physician’s life easier.”

Looks like cancer management systems are one option gaining ground in the oncology community to make the physician’s life easier–and to create value for patients and payers, too.

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ACCC’s seminar on “Navigating the Changing Landscape of Payment Models in Community Oncology” was sponsored by Cardinal Health/P4 Pathways; D3 Oncology Solutions/Via Oncology; ION Solutions; and McKesson Specialty Health.

Better Outcomes, Decreased Costs with Oncology Clinical Pathways

by Don Jewler, Director of Communications, ACCC

REPORT FROM PHILADELPHIA
Payment models in oncology are changing fast, driven by the high costs of oncology drugs, comparative effectiveness research findings, and variations in care. The 100 cancer care providers who gathered for ACCC’s seminar in Philadelphia were treated to an in-depth exploration of today’s shifting landscape in oncology reimbursement as well as the opportunities that new arrangements with insurers may offer.

The transformation will affect patients as well as providers. “We’re seeing pretty profound changes in benefit design,” said Donald Liss, MD, vice president for clinical programs and policy for Independence Blue Cross, the largest health insurer and managed care organization in the Philadelphia region. “High-deductible plans with employee-controlled spending accounts, consumer-directed health plans with high deductibles, narrow networks and increases in consumer cost sharings for health benefits.”

Employees contribute 45 percent more to their health plans than they did five years ago. From 2010 to 2011 the average employee annual premium payment increased 11.8 percent.

Providers will see increased use of bundled payments for a year’s worth of oncology care, for example, decoupling payments for drug and provider payment, more attention to precertification and accuracy in claims payment, and the promotion of adherence to accepted guidelines. Independence Blue Cross (IBC) “struggles with that,” Dr. Liss said of cancer management systems that integrate pathways into daily workflow. IBC receives “pitches” from a number of cancer management system companies to put a pathway program in place. “We look at these…We ask what are the consequences versus the benefits,” Liss said.

Why is cancer management needed? Costly drugs, for one.

“Looking forward to 2013, oncology is one of the seven therapeutic areas likely to drive the majority of drug spend 2011-2013,” said Amy L. Schroeder, RPh, senior consultant at DK Pierce & Associates, Inc.

She also cited variations in care as driving the transformation in oncology payment systems. “The use of chemotherapy in the last two weeks of life overall, for example, was about 6 percent of patients, but in some regions and academic medical centers the rate exceeded 10 percent. The use of hospice care varied markedly across regions and hospitals,” she said.

Comparative effectiveness research findings are also playing a part in payment model changes, said Amy Schroeder. The majority of employers expect CER findings to be used by their insurers.

Increasingly, commercial payers are finding value in clinical pathways. Most of the top insurers are initiating pathway approaches, focusing first on breast, colon, lung, and prostate pathways, said Amy Schroeder. Lymphomas, ovarian, and multiple myeloma are targets for expanded pathways in 2012.

Making decisions based on a clinical pathways program works well for Ray Page, DO, PhD, president and director of research at The Center for Cancer and Blood Disorders in Fort Worth, Tex. “Clinical pathways allow doctors to be more efficient in our practice. We are more predictable in our drug buys,” he said during a panel discussion.” The system also enhances his research program.

Panel participant Bruce Feinberg, MA, BS, MD, medical oncologist and vice president, CardinalHealth/P4 Pathways, used clinical pathways in his practice back in 1991, developed with a recognition that consensus would drive quality and that oncology is a complicated system. “Variance drives up costs of care, puts patients at risk. Clinical pathways can accomplish better outcomes…and decrease cost of care. That’s my experience,” he said.

Okay, so clinical pathways offer lots of benefits and provide direction in selecting appropriate care.

How can they best be integrated into provider business or web-based access?

Check back for the next blog.

The Holy Grail of Cost Savings in Oncology?

by Don Jewler, Director of Communications, ACCC

To help cancer care providers and pharmaceutical industry representatives understand the changing landscape in oncology payment, the Association of Community Cancer Centers (ACCC) is hosting a two-day seminar at the Fox Chase Cancer Center in Philadelphia, Pa., December 7-8, 2011. Day one’s common theme: Traditional reimbursement models are changing, and collaborative programs between payers and physicians are emerging because, in brief, clinical resources do not provide enough guidance, care varies widely, and oncology drugs are expensive.

“Providers want better outcomes, autonomy, and more payment,” said presenter Kurt H. Neumann, MD, FACP, vice president of Oncology Physician Resource and medical director for quality initiatives for ION Solutions, AmerisourceBergen Specialty Group. “Payers want decreased variability and increased predictability that money is being spent well.”

Increasingly, payers are using an evidence-based approach to guidelines and pathways that decreases cost trends. “If you can incentivize physicians to pick cheaper evidence-based pathways, you can save money,” said Dr. Neumann, although he acknowledged the difficulty of determining exact numbers.

Dr. Neumann knows first-hand about cost savings through pathways. He was co-medical director of the Michigan Oncology Clinical Treatment Pathways Program, a collaborative program designed to enhance the quality of care for patients with certain types of cancer.

To increase quality and cost-effectiveness, 190 oncologists in Michigan (community and academic practices) guided by a steering committee of 13, developed standard evidence-based, oncology clinical pathways over nine months in a stepwise process that would roll out over three years. All pathways were guided by efficacy first, toxicity second, and costs third. Pharmacy had limited input; third-party payers had no input. Clinical trials and hospice were considered within the pathways. In years one and two, clinical pathway compliance was required by breast, colon, lung cancer, and supportive care. In 2011 five new diagnoses were added.

Physicians had incentives to install new technology and make changes within their practice, according to Dr. Neumann. They were rewarded up front with $5,000 per participating physician. In 2011 the fee schedule was adjusted for generic products and gain sharing for participating physicians was increased an additional 10 percent. They had no incentive to prescribe expensive drugs.

“Every practice reached its compliance level. Using evidence base guidelines with concern for the total costs, the physicians decreased the variability, eliminated outliers, maintained autonomy, and achieved increased payments. I’m absolutely certain there is decreased cost,” said Dr. Neumann.

According to Dr. Neumann, the “Holy Grail” of cost savings from treating oncology patients is not from substituting similarly effective lower cost regimens for higher cost ones nor from appropriate dosing through evidence-based dosing. On the oncology continuum of care, savings of just 4 to 7 percent of the total oncology spend are achieved by substituting effective lower cost regimens for higher cost ones, appropriate dosing through evidence-based dosing, generic substitution when appropriate, and gene testing according to guidelines.

The Holy Grail of cost savings? According to Dr. Neumann, cost savings of 15 to 22 percent can be achieved by avoiding unnecessary inpatient admissions, working with patients and families to explain the benefits of end-of-life care, improving coordination between diagnosing and treating physicians to reduce redundant labs and imaging studies, reducing ER visits through well managed avoidance of side effects, and shifting to less invasive interventions.

Standardized care offers great promise for cost savings and quality care. The payback for creating guidelines and pathways that standardize care is great, said Dr. Neumann. The timeline, however, is years.

P.S. If you’re uncomfortable talking about costs instead of quality in patient care, don’t be. “Consideration of cost is not necessarily unethical,” said presenter David B. Wilson, RPh, Oncology Pharmacy Manager, at St. Luke’s Mountain States Tumor Institute, Boise, Idaho. He was quoting healthcare economist Michael Drummond, who also wrote: “Equity in healthcare may be desirable, but reducing inequalities usually comes at a price.”